Emotional changes after stroke

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Emotional changes after stroke

Why have my emotions been

affected?

If your emotions or behaviour have changed

since your stroke, or you feel different, this

may be partly caused by physical damage

to your brain. Different parts of the brain control different functions within the body – including how we feel. If the part of your

brain that normally controls your emotions becomes damaged by a stroke, the result

can be a change in how you think, feel or

behave.

No two strokes are ever the same because the part of the brain affected and the extent of the damage differs from person to person. So, you may experience very different

symptoms to someone else who has also

had a stroke.

As well as the physical damage caused by the stroke, it is normal to experience a change in your emotions after any difficult or

traumatic life experience. Stroke happens

without any warning. It takes time to come to terms with the changes that a stroke can

bring to your day to day life.

Don’t be surprised if you feel anxious, depressed, frustrated, angry or bewildered.

All of these feelings are common.

What emotional changes can

happen after stroke?

Approximately one third of stroke survivors report experiencing some emotional

problems after their stroke. Usually they

will fade away with time and you will begin

to feel more like your old self. Some of the emotional changes that arise may be more persistent than others and you may need coping mechanisms to help you deal

with them. Some of these are listed in this

factsheet.

One of the most common changes in emotion after a stroke is depression. (You can read more about this in our factsheet

F10, Depression after stroke.) Other changes that you may be

experiencing are: • anxiety

• emotionalism (having difficulty controlling

Stroke can have all sorts of different effects. Many are physical -

that you can see and recognise easily - but there can also be hidden

effects, like emotional changes. Although we cannot see feelings or

thoughts, changing emotions often lead to a change in behaviour

which may signify that all is not well. This factsheet explains some of

the emotional changes that can arise after stroke, tips for coping and

the help that is available.

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your emotions)

• personality changes

• anger.

Anxiety

Anxiety is both a physical and psychological

response to a frightening situation. If you

are anxious you will probably have feelings of fear or unease. At the same time, there

is an increase in blood flow to the heart and muscles, preparing us for action. This can be accompanied by sweating, rapid heart rate,

shortness of breath, dizziness and tremor.

Anxiety can very suddenly arise, or may develop slowly over a long period of time. It is natural to experience anxiety during stressful situations, for example, when attending a job interview or speaking in

public.

After a stroke you might experience fears or

worries connected to your health or other

aspects of your life. This is very common.

Some of the most commonly reported

worries are listed below:

1. having another stroke or TIA,

particularly whilst out in public or whilst

asleep

2. being unable to communicate in an

emergency, for example, to call an

ambulance

3. being unable to drive or return to work

4. taking medication – worrying about any side effects and whether it is helping

5. falling

6. feeling embarrassed in social situations

7. understanding how to get help from the

NHS and social services

8. waiting for test results and follow-up

appointments

9. never feeling any better

10. feeling family members have an increased risk of stroke.

These fears may be heightened if you live

alone.

Some anxiety is to be expected and is

normal and healthy. It often reduces in time.

However, if anxiety persists for a long time and begins to feel overwhelming, then you

may have developed an anxiety disorder

that you need to get some help with. Here are some signs to look out for:

• you feel irritable, have difficulty

concentrating or get tired very easily

• you are avoiding things you would

normally do – like going out to see friends, or going shopping

• you are having trouble sleeping because

you are worrying so much

• you are spending a lot of your waking hours thinking about things which worry

you

• you have a persistent feeling of dread with

physical sensations like a racing heart or restlessness.

How can I help myself?

A good start to reducing feelings of anxiety

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takes away the fear that arises from

uncertainty and gives you some control over

your situation. We can offer you support and

information by telephone or email. We can tailor an information pack to your needs, check for support services in your area, put

you in touch with local groups or help you

explore our online services. See page 10 for

our contact details.

There are also many other useful

organisations listed at the back of this factsheet that you can contact, or your doctor, family or carers may be able to help support you.

Another way to reduce anxiety is to find ways to relax your mind and body. This can be difficult to do initially, but becomes easier with practice. Try to find time to relax every day for two weeks and see if you can feel the benefits. There are lots of different ways to relax, like soaking in a hot bath, listening to calming music, meditating, deep-breathing exercises or even going for a walk. Some people find that writing down their worries

on a piece of paper helps them to feel better.

Try to find something that works for you and build it into your daily routine.

What treatments are available?

If you are in hospital you will have an informal check for anxiety. This will involve a brief chat by a member of staff and they will ask whether you have any concerns. If you have

family members visiting, they may also be asked if they have noticed anything that needs to be addressed. Any issues that arise

should be discussed with you and you should

be given information.

If anxiety is affecting your recovery or distressing you, you will need a more thorough assessment with a trained

member of staff to find out if you have developed an anxiety disorder. You may

then be referred to a specialist, such as a psychologist, who will aim to help you

overcome this.

Usually the symptoms of anxiety settle down

over time, but if this does not happen, or if you have not been seen in hospital, you

should see your GP. Your GP will help you

access the right therapy, depending on your needs. One type of therapy commonly

offered is Cognitive Behavioural Therapy (CBT). This therapy aims to help you change the way you think, feel and behave, so that

you can be more positive in your thoughts and actions.

If you are experiencing severe or prolonged anxiety and the psychological treatments have not helped, you might be offered one of the following medicines:

• medicines that treat anxiety directly

include diazepam/lorazepam, alprazolam

and oxazepam, which are all from a group

of medicines called benzodiazepines

• buspirone, another type of medicine for

anxiety

• antihistamines such as hydroxyzine. The medicines listed above are used to treat anxiety on a short term basis. Longer term medicines for anxiety include some

antidepressant medicines such as sertraline,

paroxetine and venlafaxine. If these are not

suitable for you, pregabalin is an alternative medicine. It is used to treat epilepsy, but can

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Emotionalism

Emotionalism can arise with many neurological conditions (those affecting

the brain and nervous system) and often happens after a stroke. It is a term you may hear if, since your stroke, you have become

more emotional than usual and/or have

difficulty controlling your emotions. (Other

terms for this condition include emotional lability, pathological laughing/crying and

pseudo-bulbar affect.)

You will probably find you suddenly have very

intense emotional reactions when talking to people, watching television, carrying

out tasks, or even thinking. Although

these emotions may reflect how you are feeling, you will probably express them in a particularly strong way. It might be that

your emotions are very close to the surface,

with the smallest thing setting you off. For example, you might get upset more easily, or cry at things you would never have cried at

before.

You might also have outbursts of crying for little or no reason. Similarly, you may laugh at inappropriate times (although this is less

common). You may even swing from crying to laughing quite suddenly. These reactions

usually do not mirror your actual emotions.

They often seem out of place and can come and go very quickly, unlike when you feel

genuinely upset or happy.

There are usually triggers that will cause this type of response: someone being kind to you, asking how you are, or talking about something which always makes you feel

emotional normally.

It can all be very distressing, especially if you have never been an emotional person

before. It can also be particularly difficult if you are a man because society often expects

men not to display their emotions. Such a loss of control is upsetting for a great many people, but you are not alone

and knowing this can be reassuring. There will be other people who have had similar experiences who you could talk to. Contact us to find out how to meet other stroke survivors.

Coping with emotionalism can have added

complications – it can be distressing for everyone concerned. If you feel embarrassed by your emotions, try talking openly about

your experience. The more you talk to

others, the more people will understand that the exaggerated (and often uncontrollable)

emotional reactions are a part of your stroke and not necessarily a cause for concern.

Tell people how you would like to be

treated if you become emotional. Everyone

is different but some of the following tips may help you:

• Being told not to cry will not help to stop

your tears and might lead to further frustration.

• There’s no need for others to feel

embarrassed or to avoid talking about topics that might cause you to cry. In fact, this may even delay your recovery.

• If you don’t want to get emotional, for example, if you are out socially, ask someone to distract you. They can do this simply by

changing the subject of conversation.

• If you find it harder to control your emotions when other people are

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emotional – tell them. People do not have to change their behaviour but at least it

will not be a surprise if you cry more than

usual, or choose to leave the room.

• Don’t let people ignore you, or leave the

room, unless that is what you want. • Encourage people to treat your

emotionalism as a minor inconvenience

and continue the conversation as if it will go away. It usually does.

• Touch can be helpful – on the arm or hand or even a hug if it is appropriate. This can

make you feel more emotional but you might prefer this. It’s okay to cry, and it might make you feel better.

• Tell people if you are genuinely upset so

it isn’t mistaken for emotionalism. You

will still need empathy and understanding

from time to time.

Emotionalism is usually worse soon after

the stroke happens, and often lessens or goes away as you recover. If this doesn’t happen, your GP may be able to help. Some

medicines that are used to treat depression

can also help with the control of emotions -

even if you are not depressed.

One such anti-depressant that you might be offered is called fluoxetine (Prozac). As with all medicines, there may be unwanted side effects. If these are troubling you, let your doctor know. There are a number of

anti-depressants available.

You could also ask your GP about

psychological services. Sometimes talking to someone can be very therapeutic and

can help you understand what you are going

through. These services are also a good option if you have a mixture of emotionalism

and depression.

Personality changes

Personality is a difficult concept to explain. For simplicity, we could describe

it as a combination of behaviours, thought

patterns and feelings. People who know you well may sometimes finish your sentence or predict how you will respond to something because you will normally be quite

consistent. A stroke can cause changes to your personality so that to others you may

seem like a different person altogether.

Sometimes your character traits can

be reversed, for example - if you were previously mild-mannered, you may now be more aggressive. Or, if you have always been loud and outspoken, you may now be more passive. More often, however, existing personality traits are exaggerated. You

might be unaware that your personality is different and deny that you have changed. However, your family and friends might be more aware of how you are different. There are many ways your personality

can change. Some of the most commonly

reported changes are listed below:

1. becoming impatient and irritable

2. becoming withdrawn and introspective (focussed inwards)

3. showing a loss of inhibitions, for example making inappropriate comments or swearing

4. becoming aggressive, either verbally or physically

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5. showing a loss of interest in aspects of

your life you once enjoyed

6. becoming impulsive - making sudden,

sometimes rash decisions

7. showing more stress and anger.

Even if you don’t feel as though you have

changed in any way, try to take on board other people’s comments. If everyone is telling you that they are surprised by your behaviour and that you’ve never acted in

that way before, perhaps they are right. Not

all behaviours are problematic, but if you have changed, others around you may need

a little time to adjust to the new you.

If you have become less inhibited, other

people may find your comments or behaviour upsetting and difficult to put up with. Try to understand how they are

feeling. Pause before you speak or act and

question whether or not they will view it as

appropriate.

Seek out information and support. Our information, advice and support services

can offer support to the whole family. These

services are currently available in some parts of England, Wales and Northern Ireland.

Contact us to see if we have a service near you. There are also organisations listed at

the end of this factsheet that can help. What treatments are available?

If you are concerned by changes to your personality, your GP can help by referring you to a psychological service, such as a specialist Neuropsychology service for an assessment.

Anger

As with anxiety, anger is both a physical and

psychological response. It usually occurs

when we feel intense displeasure, offence or exasperation. It is another part of our

survival strategy – the part that comes into

play when we prepare to fight. Designed to improve our performance, it may kick in if we

are provoked or attacked.

It is normal for feelings of anger to be accompanied by a surge of energy going

through the body. This is because chemicals (like adrenaline) are released which stimulate

the heart, lungs, blood vessels and nervous system.

Anger is a normal, healthy emotion that

we all feel and show from time to time,

particularly during stressful situations, like trying to do lots of things in a short space of time, or getting soaked by a passing car in the rain.

After a stroke you might find you experience anger much more frequently, have less control over your outbursts and/or get angry

over things that would not normally cause you to feel that way. You are likely to direct

this anger at your family and carers.

Typical triggers for angry outbursts are: • struggling to do something, like get

dressed, which has become more difficult since your stroke, for example, because your arm is weak or paralysed

• other people doing things for you all the time

• not having enough time to respond during conversations

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• not being able to express yourself; your wants and needs

• other people making choices and decisions for you

• getting things wrong • feeling embarrassed

• not being able to do something you enjoy

because of a disability, for example, watching your favourite programme on TV if your stroke has caused visual

problems

• being tired

• feeling overwhelmed, either by too many

people, or too many distractions going on around you, making concentration

difficult.

Although some anger is normal, it can

have a negative effect on health. It can, for example:

• cause digestive problems

• increase blood pressure

• lower your immune system • lead to depression

• lead to addictive behaviour (such as smoking).

If you have concerns about how angry you

feel – speak to your GP. How can I help myself?

Don’t be too hard on yourself. You’re bound to feel some anger and frustration after a stroke. It’s a normal part of the recovery

process – a sign that you are aware of the

changes the stroke has caused to your everyday life.

If you want to regain control over your angry

outbursts, try doing something physical to

let off steam, like jogging or dancing. If you

aren’t able to do these things, try pounding

a pillow. Another technique is to look at yourself in the mirror when you feel angry –

the image looking back at you may surprise you, provoking laughter or tears instead.

This is fine. A release of the tension that has

built up is good for you.

It is easy to be yourself with the people

nearest and dearest to you – after all, they

know and love you and will most likely

forgive you if you have a bad day. If you have become more aggressive since your stroke,

try to be aware of how your behaviour is affecting others. For example, are members

of your family crying, shouting or leaving the room because they feel frightened?

Usually, your anger will become less severe

over time as your stroke recovery continues.

The more you can do and the more you regain control, the less frustrated you will

feel. If this is not happening, or you have concerns that you are behaving aggressively,

speak to your GP about psychological services.

I’m a carer – what about me?

When people experience personality changes or become angry following an

illness, their anger is often directed at family and/or those caring for them. If you are a carer, you may from time to time be on the receiving end of angry outbursts that frighten or upset you, especially if they feel like a personal attack.

You may feel strongly that the behaviour is unfair if you have been spending a lot of time

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taking care of someone you love. Emotions

can escalate all round when people are tired

and fed up.

Sometimes, anger and aggression can be

avoided. Try to give the person you are

caring for as much choice as possible,

even down to small things like which socks they want to wear. After all, these are normal choices they would have made for themselves prior to the stroke. Be patient; allow plenty of time for them to carry out tasks and to respond to you. Pay attention; don’t ask them to do something you know they will not be able to do as failure is likely to

cause anger.

People are more likely to become frustrated and angry if they cannot think as clearly or as quickly as they did before their stroke.

Reducing distractions when doing a

particular task can help someone to focus

and concentrate on what they are doing. It is important not to get drawn into an angry

or aggressive encounter as it is unlikely to help anyone in the situation. It is also important to look after your own health and safety. Just because someone has had a stroke, it does not give them the right to

hurt or abuse you in any way.

There are coping techniques for dealing

with aggressive behaviour that may help you. These include:

• explaining that the behaviour is not

acceptable

• asking friends and family to support you by giving the same message

• being firm but polite

• using the word ‘I’ instead of ‘you’, for example, ‘I feel really upset when we argue’, instead of ‘you really upset me’. • explaining that you are frightened or

upset

• walking away

• reward or be positive about appropriate behaviour - this can reinforce the

likelihood of it happening again.

You may need to repeat yourself many times before someone begins to understand the impact that their behaviour is having on

others. If you’re finding this difficult you can

seek support by speaking to your GP or contacting us.

Psychological services

explained

Psychological services aim to encourage you to talk about your thoughts and feelings

and help you come to terms with what has happened. Accepting how life has changed

is an important step in the recovery process. With the guidance of a trained professional

you will have the opportunity to look at how the stroke has affected your life and discover ways of moving forward.

These sorts of services can be especially helpful if you have a range of problems. They allow you the space and time to talk things through at your own pace so you can gain a clearer picture of what lies ahead. Usually

this process helps you feel more in control

of life by working out and trying to find

solutions to problems.

Your GP will be able to help you access the

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waiting list. There are a range of specialists

available, depending on the resources in

your local area. They may include:

1. Social worker – offers short term counselling whilst in hospital. Can

specialise in mental health.

2. NHS counsellor or psychotherapist

– uses a talking therapy to help you

identify problems and find solutions. Often based within the GP practice.

Counsellors cannot prescribe medicine.

3. Occupational therapist – helps you

with practical tasks and to adapt to your environment. Usually helps with specific concerns and draws on a range of other

services.

4. Mental health team – provides help in

the community during difficult periods. May involve home visits and include

the support of a community psychiatric nurse (CPN).

5. Clinical psychologist – may work as

part of a community mental health team or in hospital. Can undertake a thorough assessment of mental health needs and provide individual or group therapy. Cannot prescribe medicine.

6. Clinical neuropsychologist – has

specialist knowledge of the brain and

behaviour. Can provide an assessment of cognitive and emotional functioning.

7. Consultant psychiatrist – usually

works as part of the community mental

health team. Has overall responsibility for the patients. Can provide therapy and prescribe medicine.

Therapy is also available privately (the

cost varies between therapists but can be quite expensive). There may also be local organisations which offer counselling, sometimes at a reduced cost, so it is worth

checking in your telephone directory, online or at your library for more local contacts.

Many people benefit from talking through their difficulties, but if your stroke has left you with problems communicating or understanding others, this may not be so

easy. You will probably require the specialist

skills of a speech and language therapist to

enable you to communicate as effectively as possible with others. There are many ways to communicate, including writing, drawing,

using pictures, gestures and communication aids. It may be possible for a speech and language therapist to accompany you to your appointment (although not all

counsellors will agree to this). If you think this would be helpful – why not ask?

Alternatively, there is an organisation called

CONNECT that you can contact (see Useful organisations section). They aim to find you

the right tools to make communication

possible. They also offer a counselling service to people with communication

problems, although this service is currently

limited to people living in London. For

more detailed information about

communication problems, see our factsheet

F3, Communication problems after stroke.

Looking after yourself

It is important that you are helped to

find some way to make your future life as meaningful and fulfilled as possible. Keeping up your morale is a crucial aspect of

your psychological well-being. Those around you can contribute greatly to this. They

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should ensure that they understand the reasons for any changes in your behaviour or emotions after a stroke, so they can

make sense of what has happened and help as much as possible. There are also many

things you can do yourself to improve your

psychological well-being. See factsheet F10, Depression after stroke for more ideas.

Useful organisations

All organisations are UK-wide unless otherwise stated.

Stroke Association Helpline: 0303 3033 100

Website: stroke.org.uk

Email: [email protected]

Contact us for information about stroke, emotional support and details of local services and support groups.

Anxiety UK

Tel: 08444 775 774

Website: www.anxietyuk.org.uk

A national charity for people suffering from anxiety disorders. Provides information,

support and has a range of services including therapy.

British Association for Counselling and Psychotherapy (BACP)

Tel: 01455 883 300

Website: www.bacp.co.uk

Publishes the Counselling & Psychotherapy

Resources Directory. This lists organisations,

counsellors and psychotherapists in the UK. Some counsellors operate a sliding scale of charges according to income.

British Psychological Society (BPS) Tel: 0116 254 9568

Website: www.bps.org.uk

Holds lists of counselling psychologists and clinical neuropsychologists.

Carers UK

Carersline: 0808 808 7777

(open Wed & Thur 10–12pm & 2–4pm)

Website: www.carersuk.org

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CONNECT

Tel: 020 7367 0840

Website: www.ukconnect.org

Has counsellors with personal experience of aphasia who are trained to help counsel people with communication problems.

Counselling Directory

Website: www.counselling-directory.org.uk Website listing recognised and qualified counsellors and psychotherapists with a

postcode search facility.

Different Strokes Tel: 0845 130 7172

Website: www.differentstrokes.co.uk A charity for younger people affected by

stroke.

Gofal Cymru Tel: 01656 647722

Website: www.gofal.org.uk

A range of support services for people with

mental health problems in Wales.

Mankind Initiative Tel: 01823 334244

Website: www.mankind.org.uk

Support for males experiencing domestic

abuse or violence.

MIND

Tel: 0845 766 0163

Website: www.mind.org.uk

A national mental health charity offering a

range of publications and information on local services and support groups.

Niamh Wellbeing (Northern Ireland Association for Mental Health) Tel: 028 9032 8474

Website: www.niamhwellbeing.org

A network of support services throughout Northern Ireland supporting mental well

being.

Support in Mind (Scotland) Tel: 0131 662 4359

Website: www.supportinmindscotland.org.uk

Supports people with mental health problems in Scotland, offers information,

support and a drop in resource centre.

RELATE

Tel: 0300 100 1234

Website: www.relate.org.uk

Relationships Scotland

Website: www.relationships-scotland.org.uk

Have local branches and provide counselling

for couples and individuals with relationship

problems.

UK Council for Psychotherapy (UKCP) Tel: 020 70149955

Website: www.ukcp.org.uk

Holds national register of psychotherapists and psychotherapeutic counsellors, details

what these therapies involve and how to find

a therapist.

Women’s Aid

Tel: 0808 2000 247 - 24 Hour

Website: www.womensaid.org.uk Information and support for women experiencing domestic abuse or friends/

relatives/professionals seeking information on their behalf.

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Produced by the Stroke Association’s Information Service.

For sources used, visit stroke.org.uk

Factsheet 36 version 02 published June 2011, updated April 2012 (next revision due

September 2013). Item code: A01F36

Disclaimer: The Stroke Association provides

the details of other organisations for information only. Inclusion in this factsheet does not constitute a recommendation or endorsement.